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School Refusal Behavior in Young Children International Journal of Behavioral Consultation and Therapy Volume 1, No. 3, Fall, 2005 School Refusal Behavior in Young Children Christopher A. Kearney Gillian Chapman L. Caitlin Cook Abstract School refusal behavior is defined as any child-motivated refusal to attend classes and/or difficulty remaining in classes for an entire day. Although many researchers have focused on older children and adolescents in their samples, few have specifically focused on young children aged 5-9 years (i.e., kindergarten to third grade). In this article, a general description is made of school refusal behavior, and illustrative data from 55 young children with school refusal behavior are provided. Recommendations for assessing and treating this young population are made as well. Keywords: School refusal behavior, young children. School refusal behavior refers to a child-motivated refusal to attend school and/or difficulty remaining in classes for an entire day. School refusal behavior is a particularly devastating condition for many families because the behavior often leads to increased conflict, academic and legal problems, friction with school officials, and lost time from work. The problem often involves a myriad of internalizing and externalizing behaviors, making conceptualizations based on the form of behavior traditionally difficult. In addition, such heterogeneity of behavior has stifled the development of consensus opinions regarding the assessment and treatment of this population. For a more detailed description of this population, the reader is referred to other sources (Kearney, 2001; 2003; 2005; Kearney & Albano, 2000; Kearney & Silverman, 1996). Many of the assessment and treatment studies available to clinicians regarding youths with school refusal behavior include samples of older children and adolescents. This is often done so that information can be collected regarding cognitive distortions, mood changes, intricate family dynamics, and other variables that are more difficult to assess in younger children. As a result, less information is available regarding the youngest section of youths with school refusal behavior. In particular, less information is available about the specific diagnostic and functional characteristics of children aged 5-9 years who refuse school. In our outpatient clinic for youths with school refusal behavior, we have examined children and adolescents of various ages using structured diagnostic interviews, child self- report measures, parent and teacher checklists, daily logbooks, and consultations with school officials. In doing so, we have accumulated data on 55 youths with school refusal behavior who are aged 5-9 years. In this paper, we summarize some of the diagnostic, functional, and parent data to provide researchers and clinicians with a snapshot of this population. In addition, assessment and treatment recommendations are made for this younger group. Diagnostic Data Diagnoses for this group were made by using child and parent versions of the Anxiety Disorders Interview Schedule for DSM-IV (Silverman & Albano, 1996). This interview 216 International Journal of Behavioral Consultation and Therapy Volume 1, No. 3, Fall, 2005 provides diagnostic information for various internalizing and externalizing behavior problems, with a particular emphasis on anxiety disorders. The interview has demonstrated excellent reliability and validity across different psychometric studies (DiBartolo, Albano, Barlow, & Heimberg, 1998; Silverman, Saavedra, & Pina, 2001; Wood, Piacentini, Bergman, McCracken, & Barrios, 2002). Information from the child and parent versions is integrated to provide a comprehensive diagnostic picture. Regarding youths from our clinic who are aged 5-9 years and who have school refusal behavior, primary combined diagnoses include: • Separation anxiety disorder (53.7%) • No diagnosis (22.2%) • Generalized anxiety disorder (9.3%) • Specific phobia (9.3%) • Social phobia/avoidant disorder (3.7%) • Enuresis (1.9%) The most common secondary diagnosis was generalized anxiety disorder, which affected 20.4% of youths. Other secondary diagnoses were scattered but largely included oppositional defiant disorder (13.0%) and separation anxiety disorder (9.3%). Other disorders sometimes thought to be common in this population, including attention deficit hyperactivity disorder and learning disorders, were not prevalent. Functional Data Although assessing the forms of school refusal behavior is useful, Kearney and colleagues have devised methods to also assess the function of this behavior in youths. The reader is referred to other sources for a full description of our functional model and methods of assessment (Kearney, 2001; Kearney & Albano, 2000; Kearney, Lemos, & Silverman, 2004). Briefly, however, the functional model of school refusal behavior stipulates that such behavior is generally maintained by one or more of the following conditions: • To avoid school-based stimuli that provoke a general sense of negative affectivity (anxiety and depression) • To escape aversive school-based social and/or evaluative situations • To pursue attention from significant others • To pursue tangible reinforcers outside of school Although functional assessment of this population generally involves a combination of measures, a quick, descriptive method for determining the primary reason a particular child is missing school is the School Refusal Assessment Scale, now revised (Kearney, 2002; Kearney & Silverman, 1993). Child and parent versions of the scale are available, and item means from each version are combined to derive an overall functional profile. Studies have indicated the scales to have good test-retest and interrater reliability as well as concurrent and construct validity. 217 International Journal of Behavioral Consultation and Therapy Volume 1, No. 3, Fall, 2005 Regarding youths from our clinic who are aged 5-9 years and who have school refusal behavior, we have found that the following primary functions apply: • Pursuit of attention from significant others (55.1%) • Avoidance of stimuli that provoke negative affectivity (20.4%) • Pursuit of tangible reinforcers outside of school (20.4%) • Two or more functions of equal strength (4.1%) • Escape from aversive social and/or evaluative situations (0.0%) In general, younger children often refuse school to be with parents or other significant attachment figures at home. This may result from recent and critical family transitions such as parental illness or move, but may also result from extended parental acquiescence to noncompliant behavior. Indeed, in a previous diagnostic study, oppositional defiant disorder was found to be most associated with this functional condition. However, the school refusal behavior of youths aged 5-9 years is also marked by desires for negative reinforcement as well as desires to pursue tangible reinforcers outside of school. Interestingly, none of the children in our sample refused school to escape aversive social and/or evaluative situations. This may be due to the fact that social anxiety is a largely developmental phenomenon that begins to more fully emerge in later elementary school years (Kearney, 2005). Parent Data Parent data for this group included scores from measures of child internalizing and externalizing behavior problems as well as family dynamics. Measures included the Child Behavior Checklist (CBCL) (Achenbach & Edelbrock, 1991) and Family Environment Scale (FES) (Moos & Moos, 1986), the latter of which assesses for ten dimensions of family functioning: cohesion, expressiveness, conflict, independence, achievement orientation, intellectual-cultural orientation, active-recreational orientation, moral-religious emphasis, organization, and control. Each measure has demonstrated excellent psychometric properties. On the CBCL, T scores of internalizing and externalizing behavior problems are derived. T scores of 67-70 are considered to be in the “borderline clinical range” and T scores of 70+ are considered to be in the “clinical range.” For our sample of younger children with school refusal behavior, mean T scores for the internalizing and externalizing scales were 69.7 and 58.4, respectively. In fact, 50.9% of these youths were rated in the clinical range for internalizing behavior, compared to only 11.3% of youths in the clinical range for externalizing behavior. On the FES, T scores of 50 are considered to be average functioning. In our sample of young children with school refusal behavior, FES T scores generally surrounded the norm, but two dimensions of family functioning were at least one-half of a standard deviation from the norm. In particular, independence T scores (40.6) were rated much lower than the norm, whereas moral-religious emphasis T scores (57.0) were rated much higher than the norm. 218 International Journal of Behavioral Consultation and Therapy Volume 1, No. 3, Fall, 2005 Implications for Assessment Young children with school refusal behavior appear to be characterized largely by separation anxiety, attention-seeking motives, and oppositional behavior. Often these characteristics are manifested by willful, stubborn, manipulative behaviors designed to force parental acquiescence to demands of various sorts. The fact that many of these families are marked by low levels of independence, or high levels of dependence, serves to reinforce this characterization. A common scenario is a child who refuses to attend school as well as other activities such as sleepovers, and who demonstrates oppositional
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